Hopper’s House
Child’s Registration Form
Child 1
Name ___________________________________ Boy / Girl
Birth Date _______________________________ Age ________________________
Allergies / Food Restrictions? Yes / No
________________________________________________________________________
Medications? Yes / No _________________________________________________
Other _________________________________________________________________
Child 2
Name ___________________________________ Boy / Girl
Birth Date _______________________________ Age ________________________
Allergies / Food Restrictions? Yes / No
________________________________________________________________________
Medications? Yes / No _________________________________________________
Other __________________________________________________________________
Child 3
Name ___________________________________ Boy / Girl
Birth Date _______________________________ Age ________________________
Allergies / Food Restrictions? Yes / No
________________________________________________________________________
Medications? Yes /No _________________________________________________
Other __________________________________________________________________
Child 4
Name ___________________________________ Boy / Girl
Birth Date _______________________________ Age ________________________
Allergies / Food Restrictions? Yes / No
________________________________________________________________________
Medications? Yes / No _________________________________________________
Other __________________________________________________________________
Parent/Guardian Information
Name__________________________________________________________________
Address _______________________________________________________________
City ______________________ State ________________ Zip___________________
Home Phone ________________________ Mom’s Cell ________________________
Dad’s Cell ________________________ Guardian’s Cell ______________________
Email __________________________________________________________________
Emergency Contact Information
Name __________________________________________________________________
Address _______________________________________________________________
City __________________________ State __________________ Zip ______________
Home # _____________________ Work _________________ Cell _______________
Is this person authorized to pick up your child? Yes / No
Name __________________________________________________________________
Address _______________________________________________________________
City __________________________ State __________________ Zip ______________
Home # _____________________ Work __________________ Cell ______________
Is this person authorized to pick up your child? Yes / No
Please note that anyone picking up your child(ren) will be required to show picture ID and must be allowed to pick up your child before any child will be released. This means that their name and information must be listed above.
ONE TIME REGISTRATION FEE OF $10.00, PER FAMILY, WILL BE CHARGED AT THE FIRST DROP-OFF.
Agreement:
On behalf of myself, my spouse, and each child designated my “Child” I enter into this Registration Form Agreement with Hopper’s House, LLC, regarding the provision by Hopper’s House, LLC, of a supervised, indoor play environment for my Child (ren).
Facility Use: Subject to this Agreement and other terms as drop-in, short-term Childcare for my child on a flexible time basis, this includes use of facilities and participation in play and play activities. Hopper’s House, LLC, facilities may only be used for periods of 4 hours or less on a regular basis. If for any reason a Child is present more than 4 hours, I agree that this does not constitute regular care. Hopper’s House, LLC, does not provide transportation or take field trips.
Future Visits: This agreement, the Registration form and the Child information will be kept on file at Hopper’s House, LLC, and will constitute binding obligations for any future visits my child may make to Hopper’s House, LLC. However, this agreement does not obligate Hopper’s House, LLC, to continue to provide services, and Hopper’s House, LLC, reserves the right to refuse admission to any child for any reason without liability.
Safety/ Indemnity: I agree that Hopper’s House, LLC, may take action, when it considers prudent to protect the safety of my Child, and other Children visiting Hopper’s House, LLC. I further agree to indemnify, defend and hold harmless Hopper’s House, LLC, ( and partners, directors, agents, and employees) from and against all restrictions, claims, or liability, including Attorney fees and court costs directly or indirectly caused by my Child or resulting from any inaccuracy or omission made by me in completing the Registration Form.
Additional Requirements: As a condition to my use of Hopper’s House, LLC, I have accurately completed and signed the Registration Form and Releases. I understand that Hopper’s House, LLC, will rely on this information in caring for my Child. I agree to pay all costs and attorney fees arising out of any action relating to this Agreement, the Registration Form, or the Release for collection purposes or otherwise.
Release Agreement:
Hopper’s House, LLC, provides a fun, safe environment for Children. However, in any Childcare program, injuries may occur. In order for Hopper’s House, LLC, to be able to provide drop-in Child care services to you, it is necessary that you assume certain risks. Thus, as a requirement to receive our services, Hopper’s House, LLC, is requesting that you sign this release. I, on behalf of myself, my spouse, and each Child designated on the registration form Agreement, waive and release all right, causes of action and claims against Hopper’s House, LLC., its partners, Directors, Agents, and Employees, for any and all loss of or damage to property or injuries suffered by my Child during the time my Child is visiting Hopper’s House, LLC., including possible negligence of Hopper’s House, LLC., but excluding gross negligence and intentional misconduct. I understand that the provision of Childcare contains risk of injury to persons and damage to property that by signing this release I engage Hopper’s House, LLC, to provide temporary Childcare for my Child at my own risk. I have been given an opportunity to ask questions and obtain answers to my satisfaction regarding any and all aspects of Hopper’s House, LLC, and the Release, including, but not limited to, future risks, complications and costs. By signing this release, I have not relied on any promises or statements made by Hopper’s House, LLC., other than those contained in the written information supplied to me by Hopper’s House, LLC. I understand that this Release will be kept on file at Hopper’s House, LLC, and will continue in effect for this and any future visits my Child may make to Hopper’s House, LLC.
I HAVE READ THE ABOVE CAREFULLY AND HAVE FULLY UNDERSTOOD THE CONTENT AND CONSEQUENCES OF THIS AGREEMENT BEFORE SIGNING.
________________________________________________________________________
Signature of Parent/Legal Guardian
________________________________________________________________________
Print Name
________________________________________________________________________
Signature of Hopper’s House, LLC Representative
________________________________________________________________________
Date
Snacks and Drinks
While your child is here for drop-off, you can either bring with them a drink/snack or allow HH staff to provide your child with a drink or snack or both if necessary.
If you choose to allow our staff to provide your child with a drink or snack or both, you will be charged for the drinks and snacks at time of pick-up.
I will/will not allow HH staff to provide my children with drinks/snacks.
Allowed drinks/snacks: (circle choices)
Snacks Small Soda
Small juice Large Soda
Large juice
Signature: __________________________________________ Date: ________________________________________________